Provider Demographics
NPI:1821389677
Name:SANDER, KELLY DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DAWN
Last Name:SANDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:DAWN
Other - Last Name:SEMENKEWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14000 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5713
Practice Address - Country:US
Practice Address - Phone:952-993-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55446OtherMEDICAL LISCENSE